Introduction

Avulsions or degloving injuries of the penile and scrotal skin are rare urology emergencies and occur mainly due to accidents with industrial machines and agricultural machine belts. Such lesions are incapacitating and have a devastating psychological impact. Avulsions may vary from simple lacerations to virtual emasculations. Gener-ally, lesions do not extend beyond the skin, cause mini-mal bleeding, do not damage the cavernous body, the spongy body or the testes. We present a 12 year old boy with isolated degloving penile injury.

 

Case report

 

A 12 year old boy with degloving penile trauma. He was being brought up by his biological mother and a step fa-ther after his mother and father separated. He was alleg-edly caught by the step father sexually molesting his step sister. The step father grabbed him by the private parts resulting in the injuries described. He was prevented from coming to hospital and therefore reported about 24 hours after the injury. Examination revealed a healthy boy with no other visible injuries or abnormalities. Ex-amination of his reproductive organs showed a degloved penis with skin avulsed starting just distal to the base of the penis. [fig 1] There was gross edema of the skin and surrounding tissues and impending infection. The scrotum was intact. The penile bodies and urethra were also intact, and were covered by bright red tissues with prominent blood vessels. He was passing urine with no obstruction. No attempt had been made to reposition the skin before admission. [fig 2] He was immediately prepared for operation. Intraopera-tively, under a general anesthetic, the skin was avulsed through the loose areola tissue surrounding Buck’s fas-cia. A temporary catheter was inserted. When the skin was reapposed, it was noted that about an inch of the most proximal flap was non-viable. After surgical toilet and debridement, it we created local flaps using the re-maining proximal penile skin and a part of the anterior scrotum. This proved adequate to achieve cover of the denuded penis. [fig 3] Healing went on well albeit with a minimal dorsal break down that was allowed to heal by secondary intention. The child remained in the hospital until fully healed due to social reasons. He was discharged after 18 days.[fig 4] On discharge, skin cover was complete. Reassessment at 6 months and 1 year showed no cicatrification with minimal scarring and cosmetically good results. Sen-sitivity to touch was preserved. The patient reported a mild degree of painful erection and curvature that was not bothering him.[fig 5] He remained sexually inactive.

 

Discussion

Degloving injury to the male genitalia is a rare condition usually described as a machinery or farm injury. (1,2) The common machines causing this type of injury are the rotary type that can catch on the clothing and result in the so-called power take-off injury. In children, penile trauma is even rarer, the most common being iatrogenic injury at circumcision or animal bites, especially dogs. Penile fractures are even rarer. Most literature on these types of injury relate to adults. (3) We present a unique case of degloving penile trauma presenting after assault. The unique feature of deglov-ing penile trauma is its ability to interfere with fertility and gonadal function, thus having a direct correlation with quality of life after trauma.

 

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(2) Other documented complications include infection, incontinence, erectile dysfunction, Peyronie’s disease, and hypersensitivity, or loss of sensation. Thus timely and adequate procedures must be carried out with this in mind. (4, 5)

 

The penile skin is very mobile, to accommodate the many variations in penile size. Blood supply to penile skin is inadequate from the underlying tissues. The skin is supplied by the superficial penile arterial plexus aris-ing from the two pudendal arteries, up to the prepucial ring, where it penetrates the Buck’s fascia and forms an anastomosis with the dorsal penile artery. Proximal to distal avulsion of kin therefore disrupts the most impor-tant supply, but the prepucial ring anastomosis can sus-tain the skin. Early repair is therefore of paramount im-portance, as is preventing desiccation of avulsed skin by

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wrapping the avulsed skin in moist gauze or towels. (6) In children, primary closure is advocated, unlike in the adult population. When no viable skin is available, burial in suprapubic area or scrotum is carried out. Skin grafting in genital areas is difficult to manage and in-creases the risk of complications, compared to primary closure, and should be limited to cases for which the na-tive genital skin is irreparable. (7) When skin grafting is needed, thick, nonmeshed split-thickness skin grafts of the anterior thigh or buttocks are recommended. (8) Skin graft will have varied complications such as lymph-oedema, painful erections and hypo or hypersensitivity. Multiple subsequent operations have been shown to re-sult in psychological stress. (1) McAninch et al. have shown that early debridement and proper penile and scrotal skin repair can result in accept-able cosmetic and functional results in all cases of major skin loss. (6) Our patient did not suffer from scrotal degloving, nei-ther was there injury to deep structures. However, it should be noted that in the case of penile degloving, scrotal degloving often occurs and may have significant implications on gonadal function. With the exception of functional impairment of the penis, i.e. erectile dysfunc-tion and Peyronie’s disease, fertility and gonadal func-tion should not be affected by penile degloving alone. Primary closure of our patient’s penile degloving injury was completed with no evidence of complication and normal urinary and erectile function on medium-term follow-up.

 

This good result can be attributed to the fact that the injury was not farm related, and was an isolated inju-ry. This therefore did not result in tearing of the skin.

 

Children also heal relatively well as compared to adults. However, follow up is of prime importance as appropri-ateness can only be determined after puberty.

 

Conclusion

Surgical repair of a degloving injury to the penis should be undertaken as an emergency. A single attempt at pe-nile reconstruction without a graft can be attempted. Local flaps in a child yield good results in degloving trauma.

 

References

 

1. Zanettini LA, Fachineli A, Fonseca GP. Traumatic degloving injury of penile and scrotal skin. Int Braz J Urol 2005; 31(3) 262-263

2. Ward MA, Burgess PL, Williams DH, Herrforth CE, Bentz ML, Faucher LD. Threatened fertility and gonadal function after a polytraumatic, life-threatening injury. J Emerg Trauma Shock 2010;3:199-203

3. Finical SJ, Arnold PG. Care of the degloved penis and scrotum: a 25-year experience. Plast Reconstr Surg 1999;104:2074-8.

4. Horton CE, Dean JA. Reconstruction of traumatically ac-quired defects of the phallus. World J Surg 1990;14:757-62

5. McAninch JW. Management of genital skin loss. Urol Clin North Am 1989;16:387-97

6. McAninch JW, Kahn RI, Jeffrey RB, et al. Major traumatic and septic genital injuries. J Trauma 1984;24:291-8

7. Sarin YK, Sinha A, Ojha S. “Snapped in” penis: An unusual presentation of degloving injury of the penis. Indian J Urol 2004;20:56-7

8. Bandi G, Santucci RA. Controversies in the management of male external genitourinary trauma. J Trauma 2004;56:1362-70

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